In this assignment, you will be completing a comprehensive health screening and history on a young adult. To complete this assignment, do the following:

Select an adolescent or young adult client on whom to perform a health screening and history. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one.

Complete the “Health History and Screening of an Adolescent or Young Adult Client” worksheet.

Complete the assignment as outlined on the worksheet, including:

1. Biographical data
2. Past health history
3. Family history: Obstetrics history (if applicable) and well young adult behavioral health history screening
4. Review of systems
5. All components of the health history
6. Three nursing diagnoses for this client based on the health history and screening (one actual nursing diagnosis, one wellness nursing diagnosis, and one “risk for” nursing diagnosis)
7. Rationale for the choice of each nursing diagnosis.
8. A wellness plan for the adolescent/young adult client, using the three nursing diagnoses you have identified.

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Use correct acronyms or abbreviations when indicated.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to Turnitin.

 

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Consider the following scenario:

Rene is a health care administrator who works for an Health Service Organization (HSO) in a large urban area. Because she was previously a health care provider, Rene is sensitive to the need for health care delivery that also promotes patient safety. As part of the responsibilities in working within the HSO, the board of directors has asked Rene about the needs of the HSO for fostering improvement initiatives. To that end, Rene suggested initiatives aimed at increasing patient safety in light of a recent report citing poor patient safety across all departments in the HSO. The board agreed and has made Rene responsible for developing a new patient safety initiative. Rene quickly communicated with several department leads to determine potential courses of action to improve patient safety within the HSO. A meeting to hear from each respective department with contributions on how to implement a new patient initiative is slated for next week. Several department heads and the board of the HSO have been impressed with the commitment that Rene has demonstrated thus far.

How are improvement initiatives put into place within HSOs? How might leadership and the approaches used by leaders contribute to the implementation of improvement initiatives in practice? As a current or future health care administrator, you will likely encounter improvement initiatives aimed to increase the efficiency and effectiveness of health care delivery.

For this Discussion, reflect on the scenario presented and consider the role of leadership for improvement initiatives in HSOs. Then, think about improvement initiatives currently in place at your HSO or an HSO with which you are familiar.

Post a description of the improvement initiative(s) currently in place at your Health Service Organization (HSO)  or an HSO with which you are familiar. Explain how leadership is related to the particular improvement initiative selected. Then, explain the levels of the integrated system of the HSO, and suggest two approaches that leadership might use to work within these levels to execute the improvement initiative you selected. Be specific and provide examples.

 

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HOMEWORK ASSIGNMENT:

For the second SLP, using the data that you collected for the Module 1 SLP, please do the following:

1. Calculate the mean, median, mode, variance, and standard deviation of the measurements taken in Module 1 SLP. Show your work and be sure to express each value in units.

2. Discuss which measure of central tendency you think most accurately describes the variable that you measured. Provide a thorough explanation.

3. Describe the spread/distribution of your data. Be sure to describe the variance of distribution and the concept of standard deviation as a measure of dispersion in your response.

4. Conduct a scholarly search on the internet to find reported health statistics on the variable that you are measuring. For example, if you are measuring your total daily caloric intake, American Dietetic Association. Identify the source.

Submit your (2-3 pages) paper by the end of this module.

 

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ASSIGNMENT: Create Health Information Documentation Guidelines

CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation

• <l1>Compile organization-wide health record documentation guidelines

Please review the assignment instructions below, and each of the deliverables:

Scenario: You are the new HIM Director for Community Healthcare which includes an 1) acute care hospital, an 2) attached clinic and an 3) attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines.

You first need to compile the guidelines set forth by the CMS since those are the regulatory bodies that monitor your organization.

Instructions:

1. Locate the documentation standards for the CMS Conditions of Participation.  
2. Create a table listing medical record documentation standards for CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic (RURAL HEALTH), and Longterm Care). You will have 3 tables, one for each type of facility.   See the websites for each type of facility for your table.

Hospital Standards:  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf  page   SEE CONDITION OF PARTICIPATION 482.24 MEDICAL RECORD STANDARDS

https://www.law.cornell.edu/cfr/text/42/482.24

CoP Changes:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-20.pdf

Clinic/Rural Health:    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_g_rhc.pdf 

Section 491.10

Long Term Care Facilities:  https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/LTC.html 

https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Downloads/som107ap_pp_guidelines_ltcf.pdf   (Pages 15, 57, 120, 193, 365-7, 371, and 453 within the document)

3.  Title the document as a policy and write a short explanation of the purpose of the document and how it should be used.   Please place in a memorandum format (non-APA, but more as if this were an actually requirement for your job), addressed to the Chief Information Officer of the facility.  Please place the references at the end.

 

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explain the palliative in healthcare?

 

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